Genitourinary Cancer – 3
(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Thank you Chiragbhai for additional very interesting points about Testicular cancer: 1. Elevated AFP means nonseminoma type, even if not found on histopathology. 2. Pure seminoma in early stage has a cure rate of 99%. 3. Seminoma have excellent cure rates with radiotherapy as well. 4. Unlike most solid tumors, monitoring post treatment is very frequent.
Now Chiragbhai can you tell us about how do you decide treatment plan for each patient, and what are the common chemotherapy regimens used?
Answer: Chemotherapy planning is based on Risk Classification. This classification is based on stage and tumor markers both. Patients are divided in 3 groups: Good risk, Intermediate risk, Poor risk. For patients with pure seminoma, there is no poor risk group, indicating excellent prognosis in this type, even with very advance disease otherwise.
Patients in Intermediate risk or Poor risk receive 4 cycles of BEP regimen. BEP includes Bleomycin, Etoposide, Cisplatin.
Good risk patients receive either 3 cycles of BEP or 4 cycles of EP (excluding bleomycin). EP regimen for 4 cycles gives equal results as 3 cycles of BEP. EP regimen was studied as a way to reduce risk of bleomycin toxicity, as bleomycin can cause serious lung toxicity, also Raynaud’s phenomenon. Lung toxicity is very uncommon, but can be extremely serious and even fatal. It can occur even after only one cycle, hence it is not always dose dependent. Fortunately most patients are young, hence they tolerate BEP regimen well. This is an intense regimen however, associated with significant myelosuppression (low blood counts) in many patients, and potential for nephrotoxicity if patient is not hydrated well.
Overall cure rates in Good risk patients are about 90%. Poor risk patients are cured in about 50% cases.
Que: These are amazing cure rates, over 90% in most cases. Poor risk patients seem to have some high relapse rates. What do you do for them?
Ans: Poor risk patients are also treated in same manner initially i.e. BEP 4 cycles, however follow up is more close. Early intensification of treatment, including High dose chemotherapy with Autologus Stem Cell Transplant (HDC/ASCT) has been studied without any benefit at this stage.
Patients who relapse however are frequently cured by chemotherapy known as salvage regimens.
Salvage chemotherapy options include VIP (vinblastine, ifosfamide, cisplatin), TIP (paclitaxel, ifosfamide, cisplatin) etc. These regimens provide a prolonged disease control in about 60% of patients. Some patients relapse even after salvage chemotherapy. These patients should be taken up for Autologus Stem Cell Transplant early, rather than further salvage chemotherapy. About 50-60% of patient can achieve long term disease control with Transplant. One unique feature of this transplant is the requirement for Tandem Transplant i.e. two consecutive transplants are required. Our personal experience is that young patient can tolerate this Tandem Transplant.
One other unique situation in treatment of germ cell tumors is Residual Mass after chemotherapy, with normal blood levels for tumor markers. All Residual masses should be resected as they may sometime harbor viable cancer cells. Majority of these have dead tumor cells (fibrosis, necrosis) or mature teratoma, but about 10-15% have viable cancer cells. Those with viable cancer cells need two more cycles of chemotherapy.
It is important to remember that PET-CT scan is not useful in this situation. It cannot differentiate between a mature teratoma and fibrosis. And that a mature teratoma also needs to be removed, as occasionally it can also transform into a malignant tumor.
Que: Excellent overview. How is the quality of life for these cured patients?
Ans: Their quality of life is excellent, essentially same as normal people. There are few important points however. One is infertility, risk is low however and most patients develop normal sperm count gradually. Sperm banking is nowadays offered to most patients before starting chemotherapy, if the disease is not very aggressive. There is a slightly higher incidence of cardiac, lung, renal toxicity in survivors, and ocassionally anxiety disorder, reduced hearing, peripheral neuropathy. They should be advised yearly follow up, and general health maintenance measures, such as maintaining good blood pressure, cholesterol, exercise, especially avoid smoking, healthy diet and weight control.
December 15th 2017.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org